The Medical Impact Of
A Bioterrorist Attack
Is it all media hype or clearly a potential nightmare?
Michael T. Osterholm, PhD, MPH
VOL 106 / NO 2 / AUGUST 1999 / POSTGRADUATE MEDICINE
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CME learning objectives
To understand the magnitude of the threat of
bioterrorism and the current state of unpreparedness
To recognize the distinctive nature of a bioterrorist
attack and the difficulties in identifying one
To learn the diseases of highest potential for a
bioterrorist attack
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tables
This is the third of three articles on emerging
infections
Preview: Invisible but deadly microbes wafting silently
through the environment until every corner of breathing
space is contaminated only happens on the Starship
Enterprise, right? Not according to Dr Osterholm, a
well-known expert in infectious disease and epidemiology
and a member of a task force working to prepare the
nation for such bioterrorist attacks. In this article,
he describes the realities of an event of this type and
summarizes the current state of preparedness.
Osterholm MT. The medical impact of a bioterrorist
attack: is it all media hype or clearly a potential
mightmare? Postgrad Med 1999;106(2):121-30
It was the second terrorist attack on New York's World
Trade Center towers, only this time, nobody knew about
it. Thousands of workers and visitors went about their
daily activities as if nothing unusual had happened.
There was no bomb blast, billowing smoke, or collapsing
concrete. There were no wailing sirens, no body bags,
and no flurry of rescue personnel tending the dazed and
wounded. There was no live television news coverage; the
only visual recording of the day would come from the
static eyes of security surveillance cameras. There was
no death in the streets and no wild-eyed panic that day.
That would come later. And when it did, it would be like
nothing anyone connected with managing the crisis--from
officials in the White House down to the cops on the
beat--had ever seen before.
Even 2 weeks later, no one really knows what is
happening. This is when people start showing up in
emergency departments throughout the greater New York
metropolitan area complaining of flulike symptoms:
headaches, backaches, high fever, and sometimes nausea
and vomiting. Some of them are so ill that bacterial
meningitis is considered, but test results are negative.
Patients also have a characteristic rash that
immediately suggests chickenpox to emergency department
physicians. Although some patients report that they
already had chickenpox as children, the diagnosis is not
dismissed because personal histories can be unreliable.
A few of the more perceptive physicians consider a
food-borne staphylococcal infection, which can explain
the vomiting and rash, but testing reveals nothing.
Patients are sent home with instructions to see their
own physician or return if they do not start feeling
better.
Meanwhile, a few people show up at hospitals with even
more severe flulike symptoms but no rash. Despite
aggressive medical support, each dies within 48 hours of
presentation. Autopsies show some internal bleeding in
the heart, lungs, and gastrointestinal tract, but the
actual cause of death remains a mystery.
Employers at the World Trade Center begin to notice
exceptionally high absenteeism. Because the center
represents such a large concentration of people, it is
often seen as a microcosm for infectious diseases in the
general urban New York City population. There must be a
bad cold or flu going around. Within days, the horror of
what has happened in the greater New York City area
begins to be seen around the world. The unlucky visitors
to New York on "that day" have carried home and planted
new seeds of infection. The president, mayor, press, and
American people are demanding answers from the Centers
for Disease Control and Prevention or anyone who can
provide information. The infection has become
international news--the biggest story in the world.
People who were sent home from emergency departments now
started returning, and in much worse condition. The rash
has developed into something horrible and grotesque; it
is something physicians have seen only in textbooks. The
diagnosis becomes clear: smallpox. A disease supposedly
eradicated from the face of the earth has come back to
remind people of its potential for destruction. Patients
are dying. Bodies are literally piling up in hospital
morgues that do not have enough cold storage.
Before the devastation is over many months later,
upwards of 400,000 people will have fallen ill, more
than 150,000 of whom will die. Many additional
generations of cases continue to occur in many states
and even other countries. The survivors will bear
lifelong effects, including severe scarring and, in some
cases, blindness. Widespread panic will come along after
the initial terror among healthcare workers and the
fundamental breakdown in overburdened medical services,
the closing down of Wall Street, and the most vicious
and deadly trading in black-market drugs ever witnessed.
The lasting effect on the collective psyche of a people
who are no longer able to enter a public space without
fear and have abandoned their faith in the basic
structures of government and society can only be
imagined.
For the past several decades, smallpox has been among
the most unlikely diagnoses that any clinician would
expect to make, regardless of a patient's travel history
or other risk factor. However, as noted in the preceding
chilling scenario, this could change rapidly. Today such
illnesses as smallpox and anthrax routinely make
front-page news, in part due to the recent flurry of
threatening anthrax-related hoaxes. The growing threat
of a real bioterrorism event has become one of the most
feared infectious-disease possibilities as we move into
the 21st century.
For many members of the medical community, important
questions must be answered before this threat can be
taken seriously. This article addresses the questions
that help clarify bioterrorism as either media hype or a
potential nightmare.
Historical perspective
Bioterrorism is not a new means to further political,
social, or religious agendas. In 1346, the Tartar army
hurled corpses of plague victims over the walls of enemy
settlements. However, today's changing factors make the
potential for bioterrorism in the United States very
different than it was just decades ago. These factors
include the growing number of groups and individuals
willing or determined to cause mass civilian casualties,
the unprecedented availability of traditional
biologic-warfare agents, and the means to effectively
deliver these agents to large populations. These changes
are unparalleled in human history, and because of them,
the United States must be prepared for the growing
threat of bioterrorism (1,2).
Increasing public awareness of the threat of
bioterrorism began after the fall of the Soviet Union in
the early 1990s. At that time, several defectors from
the former Soviet Union's biologic-warfare program
described in detail the efforts to use biologic agents
as weapons. The program was funded by two entities, one
(ie, Biopreparat) in the Ministry of Medical and
Microbiologic Industry and the other in the Ministry of
Defense. In the 1980s, more than 60,000 workers were
employed in Biopreparat to develop extensive weapons
systems using a variety of biologic agents. These
efforts have been graphically described in a recently
released book (3). One of the authors, Dr Ken Alibek,
was the former first deputy chief of Biopreparat. He
defected to the United States in 1992 and was one of the
first people to draw attention to the potential for use
of biologic agents against civilian populations.
The financial and structural collapse of the former
Soviet government has been a factor in the dissemination
of biologic weapons around the world. Because of severe
financial difficulties, many scientists working in
programs to develop such agents have departed, and
security is critically lax. There is substantial
evidence that a number of these scientists have moved to
countries well recognized for ongoing efforts in the
areas of terrorism and weapon development (4). In
addition, nongovernmental terrorist groups and religious
cults with scientific expertise have made extensive
efforts to procure and develop biologic weapons for use
against civilian populations.
The current situation
In 1972, more than 140 countries, including the United
States, signed the Biological and Toxin Weapons
Convention. This international attempt to eliminate the
possibility of biologic warfare or terrorism has been
largely unsuccessful in limiting proliferation of
weapons and their serious potential. It appears that
while Western countries complied, other countries
initiated massive programs in weapon development.
Complacency with the issue of bioterrorism was forever
shaken by the events surrounding the Persian Gulf War
and the discovery of Iraq's biologic-weapons program.
The 1995 release of sarin gas in the Tokyo subway by the
Japanese religious cult Aum Shinrikyo further
illustrated the world's vulnerability to bioterrorism.
Although the Japanese government attempted to dismantle
Aum Shinrikyo after the attack, the organization
continues to operate throughout the world. Today more
than 500 members are known to live in Japan, and
branches of the cult are found in Russia, Ukraine,
Belaruse, and Kazakhstan (5).
In addition, international terrorist experts recognize
that the advent of the Internet has played a key role in
the ability of terrorists, hate groups, and even
potential lone offenders to organize activities that
elude detection by traditional intelligence programs.
The Internet enables these groups and individuals to
easily obtain information regarding procurement of
potential agents and instructions on how to effectively
disseminate them.
The challenge of biologic agents
To date, most of the federal, state, and local agencies
involved in planning and training for terrorism have
focused on the classic event involving chemical release
or use of an explosive device. In these situations,
police, fire, law-enforcement, and other
emergency-response personnel descend on a scene where
causalities are evident. The news media have depicted
preparedness exercises, featuring rescuers wearing
hazardous material (HAZMAT) protective equipment, and
this training supposedly reflects our nation's
preparedness to deal with terrorism associated with
weapons of mass destruction.
Unfortunately, in the case of a biologic-agent release,
this scenario could not be further from the truth.
Because the onset of illness is often delayed, sometimes
up to weeks after the release, and because a biologic
agent can be disseminated widely throughout an entire
city or region, the timing and location of a
bioterrorism event may be extremely difficult to
identify. Instead of being heralded by red lights and
sirens converging on a known point of assault, a
bioterrorist attack will be identified gradually by
emergency department physicians, infectious-disease
consultants, clinical laboratorians, and public health
epidemiologists. Their role will be critical in
recognition of the release of a biologic agent. To date,
the public health and medical care delivery systems have
been woefully ill-prepared to meet the challenge of a
biologic-agent release (2).
Bioterrorism comes of age
Three basic ingredients must be in place for a
bioterrorism event to occur: a terrorist group or other
type of perpetrator, availability of selected biologic
agents, and an effective method of dissemination.
Existence of terrorists
In the past decade, a spectrum of potential terrorist
organizations and individuals has emerged (1). These
range from state-sponsored terrorism, such as that seen
in such countries as Iraq, Iran, Libya, Syria, Israel,
North Korea, and even Russia, to the religious extremist
groups that are causing rapidly growing concern, such as
those responsible for the bombings of US embassies in
Africa in 1998. Although the extent of biologic-weapon
development by these religious extremist groups is
unclear, some experts suggest that technology has been
transferred to the groups by several of the
state-sponsored organizations mentioned.
Recently, there is some concern that millennium cult
groups, who espouse the end of the world during the year
2000, will use biologic agents to attempt to bring about
this outcome. Other cult organizations, such as the Aum
Shinrikyo, are not related to the millennium but believe
that their mission is to eliminate all those in the
world who are not members of their organization. In
addition, anxiety is growing that splinter groups or
lone offenders, such as those who caused the explosion
of the Murrah Federal Building in Oklahoma City, may
move from explosive devices to biologic agents as a
means of bringing about terror and death in the civilian
population. Again, this possibility has been
substantially increased with the widespread availability
of information on the Internet regarding such activities
and instructions on creating devices that can
effectively disseminate biologic agents in large
buildings or communities.
Availability of agents
The World Directory of Collections of Cultures and
Microorganisms currently lists 453 repositories in 67
nations that will supply biologic agents for a variety
of purposes. For example, without requiring evidence of
professional or academic-research need, 54 repositories
will sell and ship Bacillus anthracis (the causative
agent of anthrax) and 18 will sell and ship Yersinia
pestis (the causative agent of plague). Although none of
the organizations that will sell or ship agents without
professional justification are located in the United
States, it is still possible, although illegal, for US
residents to procure these agents.
International sales of biologic agents from government
programs through the black market, particularly in the
former Soviet Union, is of serious concern and should
not be underestimated. For example, several years ago,
submarine gyroscopes were smuggled from the former
Soviet Union into Iraq, despite the illegality of the
shipments out of the former Soviet Union and the United
Nations' ban on shipments of such materials into Iraq.
This incident demonstrates the ease with which
black-market materials can be sold and moved throughout
the world.
Method of dissemination
Even with a biologic agent in hand, a terrorist can
initiate an attack only if an effective method of
disseminating the agent is available. Unfortunately,
with the many advances that have been made in
aerosol-particle technology for use in industry,
aerosolizing devices can be purchased in commercial
electronics stores. Such devices can easily create 1- to
3-micro particles. An aerosolizer, battery, and motor,
together with small tubes containing 1 to 3 million
infectious doses of a particular agent, can fit into a
device no larger than a standard-sized thermostat box.
These diminutive devices can fill a large metropolitan
skyscraper or enclosed coliseum with a highly infectious
aerosol. Once again, one of the primary reasons for
widespread disclosure of this technology has been its
availability on the Internet.
Agents of bioterrorism
Ideal characteristics of a potential biologic-warfare
agent include the following: can be produced easily and
inexpensively; can be aerosolized (into 1- to 10-micro
particles); can survive sunlight, dryness, and heat; can
cause lethal or disabling disease; can be transmitted
person to person; and cannot be effectively prevented or
treated. Unfortunately, a variety of agents meet most,
if not all, of these criteria.
Table 1 summarizes bacterial, viral, and toxic diseases
most likely to be associated with serious community-wide
acts of bioterrorism. Over the past year, a group of
experts in bioterrorism has convened at the Johns
Hopkins Center for Civilian Biodefense Studies in
Baltimore. A review on anthrax was recently published by
the group (6), and reviews on smallpox, plague,
tularemia, botulism, and hemorrhagic fever viruses will
be published in the near future. Clinicians, public
health officials, and other government officials will
find these reviews to be very helpful in recognizing and
responding to the specific diseases.
Table 1. Diseases of highest concern for potential
biologic terrorism
Bacterial
Anthrax
Q fever
Plague
Tularemia
Brucellosis
Viral
Smallpox
Viral encephalitides
Viral hemorrhagic fever
Toxic
Botulism
Ricin
Staphylococcal enterotoxin B
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Without question, smallpox and anthrax are the two
greatest threats as biologic-warfare agents. In
comprehensive reviews of these diseases, the experts at
the Johns Hopkins center examined the magnitude of
potential devastation from aerosol release of one of
these agents in a populated area.
Smallpox
Smallpox poses the most serious danger, in part because
few US citizens have any significant immunity remaining
from vaccinations received more than 30 years ago, and
an entire younger generation has received no vaccination
at all. Smallpox vaccine has not been produced worldwide
for several decades, and only very limited stockpiles
still exist. The US inventory consists of fewer than 7
million doses of vaccine. New production of smallpox
vaccine, now required to meet current federal standards,
is at least 3 and possibly 5 years away from completion.
Even a minor outbreak of smallpox would quickly
overwhelm the medical community's ability to respond
because of the highly infectious and
aerosol-transmittable nature of the disease. Other
serious aspects of smallpox are lack of any treatment
method and a 30% case-fatality rate.
Alibek and Handelman (3) have described in great detail
the extent of the former Soviet Union's program to "weaponize"
smallpox. In addition, in 1993 the Russian Foreign
Intelligence Service confirmed that North Korea was
investigating smallpox as a biologic-warfare weapon (7).
Anthrax
The role of anthrax in bioterrorism also is a serious
concern. There is no person-to-person secondary
transmission after initial release of the agent, as is
seen with smallpox, and animal studies suggest that
antibiotic treatment early in the course of inhalational
infection may be effective. Nevertheless, the possible
effects of a terrorist-associated anthrax outbreak are
frightening to contemplate (6).
In 1970, a World Health Organization expert committee
estimated that release of 50 kg of anthrax from an
aircraft over an urban population of 5 million would
result in 250,000 casualties (8), 100,000 of whom could
be expected to die if not treated. The US Congressional
Office of Technology Assessment estimated that between
130,000 and 3 million deaths could follow aerosolized
release of 100 kg of anthrax spores upwind of the
Washington, DC, area. This impact would exceed that of a
hydrogen bomb (9).
The challenge for the future
The challenge for society in dealing with the potential
of bioterrorism is daunting. Even a mild event will have
an overwhelming impact on the US healthcare system. The
illness resulting from such an attack could be
widespread, bringing unprecedented numbers of patients
to emergency departments. Medical care, clinical
laboratory, and mortuary personnel would need to have
available and use special protective measures. Because
stockpiles of critical vaccines and antibiotics are
limited, supplies would quickly run out. Panic would
likely ensue among the ill, the possibly exposed, the
worried well, and healthcare and other infrastructure
support staff.
The US government must undertake a comprehensive review
of the current level of preparedness to prevent and
respond to possible acts of bioterrorism. Henderson's
recommendations (2) serve as a good blueprint for
starting that review. Many of us who have had the
opportunity to more fully explore intelligence
information, to attempt to coordinate even initial
planning and response activities at the local level, and
to explain, repeatedly, to policymakers and the media
that HAZMAT training will not be relevant in a
bioterrorist event realize the magnitude of the task
before us.
Summary
Even with the technologic sophistication available in
the United States today, effectiveness in dealing with a
bioterrorist event is limited. Current surveillance
systems may be inadequate to detect attacks. Because the
onset of illness after exposure to an agent is delayed,
even the time and location of the attack may be vague.
In addition, most of the medical community is unfamiliar
with many of the high-threat diseases, so identification
of the problem may be further delayed. Many of us who
are involved in studying the many aspects of
bioterrorism believe that it is not a question of if
such an event will occur but rather when, as well as
which agent will be used and how extensive the damage
will be. Given the enormity of what is possible, we must
prepare for a potential nightmare.
References
Carter A, Deutch J, Zeilkow P. Catastrophic terrorism:
tackling the new danger. Foreign Affairs
1998;77(6):80-94
Henderson DA. The looming threat of bioterrorism.
Science 1999;283(5406):1279-82
Alibek K, Handelman S. Biohazard: the chilling true
story of the largest covert biological weapons program
in the world--told from the inside by the man who ran
it. New York: Random House, 1999
Miller J, Broad WJ. Iranians, bioweapons in mind, lure
needy ex-Soviet scientists. New York Times 1998 Oct
11:A12
Miller J. Some in Japan fear authors of subway attack
are regaining ground. New York Times 1998 Oct 11:A12
Inglesby TV, Henderson DA, Bartlett JG, et al. Anthrax
as a biological weapon: medical and public health
management. JAMA 1999;281(18):1735-45
Caudle LC. The biological warfare threat. In: Zajtchuk
R, Bellamy RF, eds. Medical aspects of chemical and
biological warfare. Washington, DC: Office of the
Surgeon General, 1997:451-66
World Health Organization. Health aspects of chemical
and biological weapons. Geneva, Switzerland: World
Health Organization, 1970:98-9
Simon JD. Biological terrorism: preparing to meet the
threat. JAMA 1997;278(5):428-30
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Dr Osterholm, former Minnesota state epidemiologist, is
chair and CEO, Infection Control Advisory Network, Inc,
Minneapolis, and a member of the Working Group on
Civilian Biodefense, Johns Hopkins Center for Civilian
Biodefense Studies, Baltimore. Correspondence: Michael
T. Osterholm, PhD, MPH, Infection Control Advisory
Network, Inc, 7716 Golden Triangle Dr, Eden Prairie, MN
55344.
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